by Laura Ungar, The (Louisville, Ky.) Courier-Journal

by Laura Ungar, The (Louisville, Ky.) Courier-Journal

LOUISVILLE, Ky. -- It wasn't supposed to work this way, but since the Affordable Care Act took effect in January, Norton Hospital has seen its packed emergency room become even more crowded, with about 100 more patients a month.

That 12 percent spike in the number of patients - many of whom aren't actually facing true emergencies - is spurring the Louisville hospital to convert a waiting room into more exam rooms.

"We're seeing patients who probably should be seen at our (immediate-care centers)," said Lewis Perkins, the hospital's vice president of patient care and chief nursing officer. "And we're seeing this across the system."

That's just the opposite of what many people expected under Obamacare, particularly because one of the goals of health reform was to reduce pressure on emergency rooms by expanding Medicaid and giving poor people better access to primary care.

Instead, many hospitals in Kentucky and across the nation are seeing a surge of those newly insured Medicaid patients walking into emergency rooms.

Nationally, nearly half of ER doctors responding to a recent poll by the American College of Emergency Physicians said they've seen more visits since Jan. 1, and nearly nine in 10 expect those visits to rise in the next three years. Mike Rust, president of the Kentucky Hospital Association, said members statewide describe the same trend.

Experts cite many reasons: A long-standing shortage of primary-care doctors leaves too few to handle all the newly insured patients. Some doctors won't accept Medicaid. And poor people often can't take time from work when most primary care offices are open, while ERs operate round-the-clock and by law must at least stabilize patients.

Plus, some patients who have been uninsured for years don't have regular doctors and are accustomed to using ERs, even though it is much more expensive.

"It's a perfect storm here," said Dr. Ryan Stanton of Lexington, president of the Kentucky chapter of the ER physician group."We've given people an ATM card in a town with no ATMs."

Richard Roberts, a 58-year-old Louisville resident who received expanded Medicaid through the ACA a couple of months ago, spent about 3 1/2 hours in Norton's ER this week, where he got a brace for a dislocated knee. The unemployed former highway worker said he was uninsured for about three years, has no regular doctor and went to the ER because it has the X-rays and scanning equipment to diagnose him.

Roberts said he's also gone to the ER for pneumonia and heat stroke, and would go again if needed. But he also plans to begin looking for a primary-care doctor for regular checkups and routine care. "That's what I'm pushing for," he said.

Hospital officials said they are helping patients find primary-care physicians and hope that helps eventually lessen ER visits.

But in the meantime, they said, crowding and wait times may increase for everyone, and Medicaid costs will be harder to control. A report from the Robert Wood Johnson Foundation said the average ER visit costs $580 more than a trip to the doctor's office.

Studies have shown that Medicaid patients were among the most frequent ER users before health reform, and becoming newly insured only increases ER use by giving an avenue to get treatment to patients who had been forgoing care because they couldn't afford it.

A 2007 issue brief from the Kaiser Family Foundation said Medicaid patients comprised 9 percent of the general population at the time but accounted for 15 percent of emergency visits. Researchers concluded that the most frequent users weren't substituting ERs for primary care, but rather suffered from chronic conditions and required more health care in general.

A January study in the journal Science found that getting covered under Oregon's 2008 expansion of a Medicaid program for uninsured adults increased ER use by 0.41 visits per person, or 40 percent relative to visits among a control group. All sorts of visits went up - those for serious problems, as well as "for conditions that may be most readily treatable in primary-care settings."

Enter Obamacare, which in Kentucky added 330,615 people to the Medicaid rolls by expanding the program to cover residents earning up to 138 percent of the federal poverty level - $15,856 for an individual in 2013.

State officials said newly signed-up recipients are reflected in the number of overall Medicaid patients seen in ERs in March, which is up 9 percent compared with the same month last year.

Claims data from Passport Health Plan, a Louisville-based Medicaid managed-care organization, separates out the newly insured, and suggests they are slightly more likely to use emergency rooms than traditional Medicaid patients.

Too few doctors

Bill Wagner, executive director of Family Health Centers, a Louisville-based network of clinics serving the poor, echoed many others about why people are flocking to ERs: "More than anything, this highlights the shortage of primary-care physicians."

Overall, University of Kentucky figures show the state had 9,273 practicing physicians in 2012. The federal government categorizes 48 of Kentucky's 120 counties as areas with too few primary-care physicians.

"We still turn some patients away," Wagner said. "Overall in the community, there's still a shortage. ... The demand may get out ahead of the supply for a while."

A workforce capacity study conducted for the state by Deloitte Consulting last year found that Kentucky needed 3,790 more doctors, including 183 more primary-care physicians, to meet pre-ACA demand. Under the law, it said the state may need to add an additional 284 primary-care physicians by 2017. Complicating matters, a quarter of Kentucky's primary-care doctors could be ready to retire within five years, the report said.

The report also said roughly 56 percent of the state's primary-care physicians, and 22 percent of all physicians, accepted a Medicaid payment in 2011, which Deloitte said was its best estimate for figuring out how many physicians accept Medicaid.

While primary care may be difficult to find, emergency rooms cannot turn anyone away. Stanton said every patient who comes in must have a medical screening, and most doctors do more; "the vast majority ... do treatment to decrease medical and legal risk."

"If people aren't used to the (health care) system, they may have problems accessing primary-care providers," said Diana Mason, who is president of the Washington, D.C.,-based American Academy of Nursing and has researched the issue.

Dr. Stephen Houghland, Passport's chief medical officer, said his company tries to connect new members with primary care and let them know how to use it. But addresses and phone numbers frequently change, so the staff works with advocacy groups to help spread the word.

Doctors and hospital officials said ER staff members try to let people know when it's appropriate to use the department, when they should use immediate care centers and when they should seek care at a doctor's office. They also refer patients to providers such as Family Health Centers for follow-up.

Mason said another promising solution is "care coordination," in which primary-care doctors work with high-risk patients to help them control illnesses and navigate the health care system. She pointed to a study showing care coordination helped reduce ER visits by 9 percent from 2011 to the first half of 2013 among Oregonians in the pre-ACA expanded Medicaid program.

Mason said letting nurse practitioners practice and prescribe on their own also may help by giving people another treatment alternative.

But Mason and others said such efforts may not immediately alleviate the crunch on ERs.

"It will continue to go up if we don't build our primary-care capacity," she said. "It will continue to go up if we don't support alternatives such as retail clinics. And it won't get better if we don't educate the public about the correct use of emergency departments."